From product dispensing to patient care: The role of the pharmacist in providing pharmaceutical care as part of an integrated disease management approach

During the past decade, the profession of pharmacy has changed dramatically. The Doctor of Pharmacy degree has replaced the Bachelor of Science degree as the first professional degree offered at most accredited U.S. pharmacy schools. Advanced clinical training is now a mainstay of pharmacy training, and this has enabled pharmacists to contribute to disease management efforts. In addition, technological improvements in prescription processing have afforded pharmacists more time to participate in disease management activities. This paper describes how the role of the pharmacist has changed and reviews the results of programs involving pharmacists as disease management providers in the areas of asthma, hypertension, diabetes, and hyperlipidemia. Pharmacists\u27 contributions in various practice settings are also discussed

Link between foot pain severity and prevalence of depressive symptoms

OBJECTIVE: Associations between pain and depression are well known, yet foot pain, common in populations, has been understudied. This cross-sectional study examined foot pain and severity of foot pain with depressive symptoms in adults. METHODS: Framingham Foot Study (2002-2008) participants completed questionnaires that included questions about foot pain (yes/no; none, mild, moderate, or severe pain) and the Center for Epidemiologic Studies Depression Scale (scores ≥16 indicated depressive symptoms). Age and body mass index (BMI) were also assessed. Sex-specific logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations of foot pain with depressive symptoms, adjusting for age and BMI. In a subset, further models adjusted for leg pain, back pain, or other joint pain. RESULTS: Of 1,464 men and 1,857 women, the mean ± SD age was 66 ± 10 years. Depressive symptoms were reported in 21% of men and 27% of women. Compared to those with no foot pain and independent of age and BMI, both men and women with moderate foot pain had approximately a 2-fold increased odds of depressive symptoms (men with severe foot pain OR of 4 [95% CI 2.26-8.48], women with severe foot pain OR of 3 [95% CI 2.02-4.68]). Considering other pain regions attenuated ORs, but the pattern of results remained unchanged. CONCLUSION: Even after we adjusted for age, BMI, and other regions of pain, those reporting worse foot pain were more likely to report depressive symptoms. These findings suggest that foot pain may be a part of a broader pain spectrum, with an impact beyond localized pain and discomfort

Clinical recognition of symptomatic midfoot osteoarthritis: findings from the clinical assessment study of the foot

Purpose: Osteoarthritis (OA) is a common yet poorly understood cause of disabling foot pain. In the absence of radiographic confirmation of OA, clinical diagnosis in primary care is inhibited by lack of evidence informing clinical examination. This study aimed to determine whether the presence of symptomatic midfoot OA (SMOA) can be clinically identified in older adults with midfoot pain presenting to primary care.Methods: A diagnostic model using brief clinical assessments was developed using cross-sectional data from 274 adults aged ≥50 years who had self-reported midfoot pain in the last month and attended a research assessment clinic between 2010-2011. All clinical assessment data were collected by trained physiotherapy or podiatry assessors adhering to a standardised, quality-controlled protocol. Presence of radiographic midfoot OA in at least one of four scored joints (1st and 2nd cuneo-metatarsal joint, navicular-first cuneiform joint, and talo-navicular joint) was ascertained by a single reader using a validated atlas and scoring system, and who was blinded to the clinical assessment data. Radiographic OA was defined as a score of ≥2 for osteophytes or joint space narrowing on either weight-bearing dorso-plantar or lateral views. SMOA was defined as co-occuring radiographic OA and midfoot pain. One foot per participant was entered into the analysis. The selection of predictor variables was based on known associations with OA or mechanically-driven putative links to SMOA. Significant predictor variables (p<0.25 from likelihood ratio tests) from univariable analyses were simultaneously entered into a multivariable logistic regression model and backward elimination (p=0.05) was performed. The Hosmer-Lemeshow statistic assessed the calibration of the refitted model and the area under the curve (AUC) evaluated discrimination. Histograms visually summarised discrimination. Internal validation of the model was performed using 1000 bias-corrected bootstrap samples with replacement.Results: 274 participants without inflammatory disease comprised 125 men and 149 women (mean age 65 yrs, SD 9). Of these 155 had midfoot pain and 119 had SMOA. 16 univariable analyses identified 9 significant predictors and no collinearity was observed. In addition to force-entered variables (age, gender, body mass index (BMI)), only two independent predictors of SMOA were retained in the multivariable analysis: (i) reduced ankle dorsiflexion with the knee flexed and (ii) absence of a midfoot exostosis. Based on the strength of univariable association, the Foot Posture Index, subtalar inversion and ankle dorsiflexion with the knee extended appeared too weak to contribute to the final model, whereas the removal of the Arch Index and foot length-corrected navicular height was due to the stronger influence of age explaining these relationships. The final fitted model was well calibrated (p=0.79) but discrimination was poor (AUC, 0.69; 95%CI: 0.62, 0.75). Bootstrapping revealed a small degree of overfitting. The use of categorical predictor variables in continuous form did not identify any other predictors, nor did it improve model performance.Conclusions: Brief clinical assessments offer only marginal improvement to age, gender and BMI for identifying SMOA. Milder severity in a population sample, random and systematic error in the clinical assessment, and variable expression of SMOA disease manifestation may have contributed to poor diagnostic accuracy. A clinically defined SMOA phenotype based on modifiable joint loading characteristics may offer an alternative approach to facilitating the development of more targeted biomechanical interventions

Uncertainty in the measurement of indoor temperature and humidity in naturally ventilated dairy buildings as influenced by measurement technique and data variability

[EN] The microclimatic conditions in dairy buildings affect animal welfare and gaseous emissions. Measurements are highly variable due to the inhomogeneous distribution of heat and humidity sources (related to farm management) and the turbulent inflow (associated with meteorologic boundary conditions). The selection of the measurement strategy (number and position of the sensors) and the analysis methodology adds to the uncertainty of the applied measurement technique. To assess the suitability of different sensor positions, in situations where monitoring in the direct vicinity of the animals is not possible, we collected long-term data in two naturally ventilated dairy barns in Germany between March 2015 and April 2016 (horizontal and vertical profiles with 10 to 5 min temporal resolution). Uncertainties related to the measurement setup were assessed by comparing the device outputs under lab conditions after the on-farm experiments. We found out that the uncertainty in measurements of relative humidity is of particular importance when assessing heat stress risk and resulting economic losses in terms of temperature-humidity index. Measurements at a height of approximately 3 m-3.5 m turned out to be a good approximation for the microclimatic conditions in the animal occupied zone (including the air volume close to the emission active zone). However, further investigation along this cross-section is required to reduce uncertainties related to the inhomogeneous distribution of humidity. In addition, a regular sound cleaning (and if possible recalibration after few months) of the measurement devices is crucial to reduce the instrumentation uncertainty in long-term monitoring of relative humidity in dairy barns (C) 2017 The Authors. Published by Elsevier Ltd on behalf of IAgrE.The work was financially supported by the German Federal Ministry of Food and Agriculture (BMEL) through the Federal Office for Agriculture and Food (BLE), grant number 2814ERA02C.Hempel, S.; König, M.; Menz, C.; Janke, D.; Amon, B.; Banhazi, T.; Estellés, F.... (2018). Uncertainty in the measurement of indoor temperature and humidity in naturally ventilated dairy buildings as influenced by measurement technique and data variability. Biosystems Engineering. 166:58-75. https://doi.org/10.1016/j.biosystemseng.2017.11.004S587516

Epidemiology of Shoe Wearing Patterns Over Time in Older Women: Associations With Foot Pain and Hallux Valgus.

BACKGROUND: Foot problems are prevalent in older women and are thought to be associated with footwear. This study examined women's shoe wearing patterns over time and evaluated associations between footwear characteristics and foot pain and hallux valgus. METHODS: Women aged 50-89 years (n = 2,627) completed a survey that included drawings of four toe-box shapes and four heel heights. For each life decade, participants indicated which footwear style they wore most of the time. Foot pain in the past 12 months and hallux valgus were documented by self-report. Logistic regression examined associations between heel height, toe-box shape, foot pain and hallux valgus. RESULTS: Wearing shoes with a high heel and very narrow toe box between the ages of 20 and 29 was common, but decreased to less than 10% by the age of 40. Compared with women who had worn shoes with a very wide toe box, the likelihood of hallux valgus increased in those who had worn shoes with a wide (odds ratio [OR] 1.96, 95% CI 1.03-3.71), narrow (2.39, 1.29-4.42) and very narrow (2.70, 1.46-5.00) toe box between the ages of 20 and 29 and those who wore shoes with a very narrow toe box (1.93, 1.10-3.39) between the ages of 30 and 39. CONCLUSIONS: Women wear shoes with a lower heel and broader toe box as they age. Wearing constrictive footwear between the ages of 20 and 39 may be critical for developing hallux valgus in later life

Reliability of the TekScan MatScan® system for the measurement of plantar forces and pressures during barefoot level walking in healthy adults

<p>Abstract</p> <p>Background</p> <p>Plantar pressure systems are increasingly being used to evaluate foot function in both research settings and in clinical practice. The purpose of this study was to investigate the reliability of the TekScan MatScan^®system in assessing plantar forces and pressures during barefoot level walking.</p> <p>Methods</p> <p>Thirty participants were assessed for the reliability of measurements taken one week apart for the variables maximum force, peak pressure and average pressure. The following seven regions of the foot were investigated; heel, midfoot, 3^rd-5^thmetatarsophalangeal joint, 2^ndmetatarsophalangeal joint, 1^stmetatarsophalangeal joint, hallux and the lesser toes.</p> <p>Results</p> <p>Reliability was assessed using both the mean and the median values of three repeated trials. The system displayed moderate to good reliability of mean and median calculations for the three analysed variables across all seven regions, as indicated by intra-class correlation coefficients ranging from 0.44 to 0.95 for the mean and 0.54 to 0.97 for the median, and coefficients of variation ranging from 5 to 20% for the mean and 3 to 23% for the median. Selecting the median value of three repeated trials yielded slightly more reliable results than the mean.</p> <p>Conclusions</p> <p>These findings indicate that the TekScan MatScan^®system demonstrates generally moderate to good reliability.</p